A classic, comprehensive health insurance plan for families and individuals who want more predictable health care costs.

BLUE

Care

How it WorksWith this classic health insurance plan from Blue Cross Blue Shield ofNorth Dakota (BCBSND) you:

• Pay the same copayment (copay) each time you visit the doctor or pharmacy.

• Share costs with BCBSND for other services, depending on the coinsurance and deductible you choose.

• Can better predict your health care expenses.

When you go to the doctor or a specialistYou pay a copay for the visit. You may have to pay additional for extra tests, lab work or other medical services resulting from that visit. The exception is preventive care, which is covered at 100%. There is no copay and no requirement to meet your deductible.

When you get prescription drugsYou pay a copay for your prescription drugs. Both brand name and generic drugs are covered, but you’ll save money by using generics.

Actively manage your health and prevent diseases

Earn rewards for taking active steps to improve your health and well being. Visit your BCBSND member portal to fi nd out more.

HealthyBlue

When you’re admitted to the hospitalYou pay toward the hospital costs until your deductible is met. After that, you and BCBSND share the medical costs (coinsurance) until your out-of-pocket maximum is met. Then BCBSND pays all your covered expenses.

Cost sharing amounts apply to covered services you receive within the Preferred Blue PPO network. For a family plan, an individual on the plan must meet the individual deductible before coinsurance begins.

Get a Quote BCBSND.com/shop 800-280-BLUE (2583) Contact your local agent

Choose a health care provider in the Preferred ProviderOrganization (PPO) network.In North Dakota, the network is the Preferred Blue PPO. If a family member resides outside of North Dakota, their network is the BlueCard PPO/EPO. You can see who’s in network by using the “Find a Doctor” link at BCBSND.com. Providers who are not Preferred Blue or BlueCard PPO heath care providers are out-of-network. Services received out-of-network are paid at a lower level.You can locate pharmacies anywhere in the United States by using the “RX Tools” link at BCBSND.com. Click on “Pharmacy Listings”, Locate a Pharmacy” and you will be taken to BCBSND’s pharmacy benefi t manager, Prime Theraputics website. You can proceed to search pharmacies by ZIP code, city/state, or address.

Health care reform has changed some things about health insurance plans. First, most Americans are required to have health insurance coverage*. Second, everyone must be accepted for coverage, regardless of health history. And third, the federal government requires all insurance plans to cover 10 essential health benefi ts (designated below).

BlueCare from BCBSND meets all the government requirements, plus has the advantage of being provided by North Dakota’s most preferred health insurance company.

10 Essential Health Benefi tsDefi ned by the federal government, every health insurance plan must cover these 10 items:

1. Preventive and wellness services as well as chronic disease management

2. Prescription drugs

3. Maternity and newborn care

4. Laboratory services

5. Outpatient services

6. Hospitalization

7. Emergency services

8. Pediatric services, including dental and vision care

9. Mental health and substance use disorder services

10. Rehabilitative and habilitative services and devices

*Find out if you qualify for help paying your premiums. Go to BCBSND.com/shop

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Plan OptionsIf you’ve had insurance before, you’ll notice plans that meet the new government requirements may cost more. We o� er you two ways to control your costs by choosing the level of deductible.

BlueCare Silver Plans These options are part of a category the federal government deems a Silver Plans.

Doctor visitChiropractic carePhysical, speech &

occupational therapyPreventive

care Prescription drugs Deductible CoinsuranceEmergency room visit

Hospitalization/Exams/etc.

Out-of-pocket maximum

Option 2: BlueCare 70 5000

You pay $50 You pay $0 You pay Generic – $20Preferred Brand – $100Non-preferred Brand – $200Specialty – 30% of total cost*

$5,000 Individual$10,000 Family

70/30 (BCBSND pays 70%; You pay 30%)

You pay $300

30% of total cost* The most you would pay per year $8,150 Individual$16,300 Family

**Option 3: BlueCare 70 4200

You pay $50 You pay $0 You pay Generic – $20Preferred Brand – $100Non-preferred Brand – $200Specialty – 30% of total cost*

$4,200 Individual$8,400 Family

70/30 (BCBSND pays 70%; You pay 30%)

You pay $300

30% of total cost* The most you would pay per year $8,150 Individual$16,300 Family

BlueCare Gold Plan This option is part of a category the federal government deems a Gold Plans.

Doctor visitChiropractic carePhysical, speech &

occupational therapyPreventive

care Prescription drugs Deductible CoinsuranceEmergency room visit

Hospitalization/Exams/etc.

Out-of-pocket maximum

Option 1: BlueCare 70 2000

You pay $25 You pay $0 You pay Generic – $10Preferred Brand – $80Non-preferred Brand – $150Specialty – 30% of total cost*

$2,000 Individual$4,000 Family

70/30 (BCBSND pays 70%; You pay 30%)

You pay $500

30% of total cost* The most you would pay per year $8,150 Individual$16,300 Family

All BlueCare plans include HealthyBlue:Earn rewards for actively managing your health.

Get a Quote BCBSND.com/shop 800-280-BLUE (2583) Contact your local agent

All cost sharing amounts apply to covered services you receive within the Preferred Blue PPO network. Covered services received out-of-network are paid at a lesser benefi t amount or no benefi t amount.

For a family plan, an individual on the plan must meet the individual deductible before coinsurance begins.

To locate a listing of participating providers, visit BCBSND.com and click on FIND A DOCTOR.

The BlueCare prescription drug coverage is considered creditable coverage.

* After deductible is met. ** This is an o� -exchange plan only and is not available for purchase within the federal exchange.

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Get a Quote BCBSND.com/shop 800-280-BLUE (2583) Contact your local agent

Health Insurance is about Sharing CostsHealth insurance is a cost-sharing arrangement. Like your auto insurance, you pay a premium. Then if you need to use the insurance, you pay a portion of the expenses and the insurance company pays a portion.

The cost-sharing terms you should know are defi ned below.

A Few Cost-sharing Terms You Should KnowPremiumThe amount you pay each month for yourhealth insurance plan.

Copayment (copay)A fi xed amount you pay for a covered healthcare service, typically paid at the time of the service. The amounts vary depending uponthe service you receive.

CoinsuranceYour share of the costs of a health careservice covered in your plan after the deductibleis met.

DeductibleThe amount you owe for health care servicesbefore your insurance begins to pay. For example, if your deductible is $1,000, you will pay all your expenses up to $1,000. After that, the insurance company will share in the cost of covered services. Some services, such as preventive services, arepaid right away, before you meet your deductible.

Out-of-pocket maximumThe most you would pay in a calendar year,including copays, before your health insurance begins to pay 100% of the allowed amount.The out-of-pocket maximum doesn’t include your premium and charges that are over and above the allowed amount.

Cost-sharing ExampleUnder the new health reform law, here’s an example of what cost sharing looks like. Chris has BlueCare 70 2000. With this plan Chris pays 30% coinsurance, has a $2,000 deductible and an out-of-pocket maximum of $8,150.

Early in the year, Chris breaks her arm and goes to the Emergency Room.

Chris pays $500 (copayment); insurance pays the remaining amount.

Later, Chris’ arm requires surgery.

Chris pays all expenses up to $2,000 (her deductible).For the remaining amount, Chris pays 30% of the expenses (coinsurance); insurance pays 70%.

Eventually, Chris reaches her $8,150 out-of-pocket maximum.

At this point, insurance pays the full cost of covered health care services for the rest of the calendar year.

January 1st Beginning of calendar year

December 31stEnd of calendar year

Note: For a family plan, an individual on the plan must meet the individual deductible beforecoinsurance begins.

Why Choose Us for Your Health Insurance?The Most Trusted Name in Health Insurance

• 98% of all doctors and 100% of all hospitals in North Dakota are BCBSND participating providers

• Enjoy protection when you travel – within or outside the U.S.

• 80% of all providers in the U.S. participate with Blue Cross Blue Shield

• To fi nd nearby doctors and hospitals, call BlueCard Access at 1.800.810.BLUE (2583) or visit the Blue National Doctor & Hospital Finder at www.BCBS.com.

When you arrive at the participating doctor’s o� ce or hospital, show the provider your ID card. The provider will identify your benefi t level through this symbol:

Ease of Use• Insurance that’s easy to use is a top

priority for our members, so we focus on convenience

• Service from local o� ces throughout North Dakota

• Hassle-free claims

• Claims paid and questions answered here in North Dakota

• Online self-service center available 24/7

A Strong, Local Company• Members and health care providers in

North Dakota appreciate the fact that they can rely on us

• Strong and stable North Dakota-based company

• 70+ years in North Dakota’s unique health care market

Ways to Stay Healthy and ActiveBCBSND believes in a preventive approach to health and wellness. To help you incorporate healthy choices into your everyday , we provide:

• HealthyBlue online wellness center with mobile app and incentive plan that rewards healthy behaviors like physical activity and setting and achieving goals.

• BlueAlliance, a partnership with North Dakota providers to improve quality, manage costs and enhance your experience

• Prenatal Plus to help facilitate healthy pregnancy

A Variety of OptionsFor individuals and families who don’t purchase insurance from employers, BCBSND also o� ers:

• BlueDirect

• SimplyBlue

• BlueEssential

BCBSND.com/shop

800-280-BLUE (2583)

Contact your local agent

Get a Quote

Do You Qualify for Help Paying Your Premium? See how much your insurance will cost by answering a few questions. Visit BCBSND.com/shop.

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This benefi t grid presents a brief overview of covered services and payment levels of this product. It should not be used to determine whether your health care expenses will be paid. The written benefi t plan governs the benefi ts available.

For premium rates and further details of the coverage, including defi nitions; exclusions; criteria for medically appropriate and necessary care; credentialing process; confi dentiality policy; description of experimental drugs, medical devices or treatments; grievance and appeals process; provider listings; drugs eligible for coverage; reductions or limitations; and the terms under which this benefi t plan may be continued, call, write or visit Blue Cross Blue Shield of North Dakota.

Blue Cross Blue Shield of North Dakota has entered into an agreement with CMS to provide health insurance coverage through Qualifi ed Health Plans on the Health Insurance Marketplace.

Prime Theraputics LLC is an independent company that manages the pharmacy benefi t program on behalf of Blue Cross Blue Shield of North Dakota.